[Bullous pemphigoid manifesting as dyshidrotic eczema and prurigo nodularis]

A 63-year-old woman presented simultaneously with two rare forms of bullous pemphigoid. Initially she had a dyshidrotic palmoplantar eczema. Repeated epicutaneous patch tests ruled out a type IV allergic reaction to common allergens. Six months later the patient developed disseminated pruritic nodules. After 4.5 years she then demonstrated scattered bullae within erythematous plaques indicative of bullous pemphigoid. A skin biopsy showed linear IgG and IgM as well as C3 deposits at the dermo-epidermal junction and circulating autoantibodies against the basement membrane could be found in serum. Accordingly, the diagnosis of bullous pemphigoid was made. In retrospect, the vesicular palmoplantar eczema and pruritic nodules could be interpreted in this case as early manifestations of bullous pemphigoid. We recommend that in patients with persistent pruritic skin lesions, which are resistant to standard therapy, bullous pemphigoid should be excluded by adequate immunological examinations.